title: Marked reduction in mortality in patients with severe traumatic brain injury.
abstract: OBJECTIVE
  In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines.
  
  
  METHODS
  The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers.
  
  
  RESULTS
  From 2001 to 2009, the case-fatality rate decreased from 22% to 13% (p < 0.0001), a change that remained significant after adjusting for factors that independently predict mortality (adjusted OR 0.52, 95% CI 0.39-0.70; p < 0.0001). Guidelines adherence increased, with the percentage of patients with ICP monitoring increasing from 56% to 75% (p < 0.0001). Adherence to cerebral perfusion pressure treatment thresholds increased from 15% to 48% (p < 0.0001). The proportion of patients having an ICP elevation greater than 25 mm Hg dropped from 42% to 29% (p = 0.0001).
  
  
  CONCLUSIONS
  There was a significant reduction in TBI mortality between 2001 and 2009 in New York State. Increase in Guidelines adherence occurred at the same time as the pronounced decrease in 2-week mortality and decreased rate of intracranial hypertension, suggesting a causal relationship between Guidelines adherence and improved outcomes. Our findings warrant future investigation to identify methods for increasing and sustaining adherence to evidence-based Guidelines recommendations.
authors.affiliation: Departments of Public Health and.
authors.forename: Linda M
authors.initials: LM
authors.lastname: Gerber
authors.forename: Ya-Lin
authors.initials: YL
authors.lastname: Chiu
authors.forename: Nancy
authors.initials: N
authors.lastname: Carney
authors.forename: Roger
authors.initials: R
authors.lastname: Härtl
authors.forename: Jamshid
authors.initials: J
authors.lastname: Ghajar
mesh_terms: D000293:Adolescent; D000328:Adult; D001930:Brain Injuries / Q000401:mortality* / Q000628:therapy; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data* / Q000639:trends; D006801:Humans; D019586:Intracranial Hypertension / Q000453:epidemiology* / Q000628:therapy; D016015:Logistic Models; D008297:Male; D009518:New York / Q000453:epidemiology; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D014193:Trauma Centers / Q000706:statistics & numerical data* / Q000639:trends; D015599:Trauma Severity Indices; D055815:Young Adult